Primary Care-Mental Health Integration Co-Located, Collaborative Care: An Operations Manual

Transcription

1 Primary Care-Mental Health Integration Co-Located, Collaborative Care: An Operations Manual Margaret Dundon, PhD 1 National Program Manager for Health Behavior National Center for Health Promotion and Disease Prevention Katherine Dollar, PhD Acting Director of Clinical Operations Center for Integrated Healthcare Mary Schohn, PhD 1 Acting Director, Mental Health Operations VA Central Office Larry J. Lantinga, PhD Associate Director Center for Integrated Healthcare 1. Formerly with the Center for Integrated Healthcare March 2011

2 Acknowledgements and Disclaimers This manual is an update of the 2005 version, developed by Drs. Mary Schohn and Larry J. Lantinga, with significant input from Dr. Kirk Strosahl of Mountainview Consulting (a pioneer in integrated primary care implementation) and several key VISN 2 Integrated Primary Care clinicians and leaders. This newly updated version reflects changes in VHA policies and refinement of procedures, and includes input from collaborative leaders in the field. The authors particularly acknowledge the review and input of Drs. Laura O. Wray, and Gregory P. Beehler. In the truest sense, this manual and its soon-to-be-released companion Educational Manual represent an extraordinary degree of collaboration among all participants. It should be noted that the U.S. Department of Veterans Affairs did not plan or authorize this manual. The guidance contained is not to be construed as official or reflecting the views of the U.S. Government or any other institution public or private. The authors have no financial or other conflicts of interest to disclose. The Authors PC-MHI Co-located Collaborative Care Operations Manual June

3 Table of Contents EXECUTIVE SUMMARY... 5 CHAPTER ONE: PURPOSE, BACKGROUND, AND CONCEPTUAL FRAMEWORK... 8 Purpose of Manual... 8 Primary Care Mental Health Integration Requirements... 8 Mission Statement... 9 Conceptual Framework Contrast with Specialty Mental Health Integration Support Systems CHAPTER TWO: ROLES AND RESPONSIBILITIES OF BEHAVIORAL HEALTH PROVIDERS WITHIN PRIMARY CARE-MENTAL HEALTH INTEGRATION Introduction Types of PC-MHI Behavioral Health Providers Definition of Roles Defining Characteristics of CCC Services Included in CCC Additional Non-Codable Functions Services Not Available in PC-MHI Programs by Either CCC or CM Service Agreements CHAPTER THREE: PROGRAM MANAGEMENT Part 1 Personnel Recruiting Hiring Position Descriptions/Functional Statements Performance Plans Supervising Local Supervision VISN Level Supervision National Resources New CCC Provider Training Part 2 Program Monitoring and Implementation Program Monitoring National Monitoring Program Implementation CHAPTER FOUR: LOGISTICS AND ADMINISTRATIVE PROCEDURES Space Coding Stop Codes Coding Encounters Specific Information for Health and Behavior Codes Clinic Schedule Standards Staffing Guidelines PC-MHI Co-located Collaborative Care Operations Manual June

4 REFERENCES APPENDICES Appendix A Service Agreement Appendix B Sample CCC Recruitment Advertisement Appendix C Sample CCC Interview Items PBI and Non-PBI Questions Appendix D Robinson & Reiter (2007) Core Competency Checklist Appendix E Sample Functional Statement Appendix F Sample Performance Plan Appendix G Sample Language for Local CC PC-MHI Supervisors Appendix H Implementation Checklist Appendix I Note Template Appendix J Dissemination Guidance Appendix K Additional Resources PC-MHI Co-located Collaborative Care Operations Manual June

5 Executive Summary: Operations Manual Primary Care-Mental Health Integration: Co-Located, Collaborative Care The following manual is provided to the field as operational support in service of successful and sustainable Co-located, Collaborative Care (CCC) Primary Care-Mental Health Integration (PC- MHI). Truly integrated healthcare involves a radical shift in conceptualizing care and challenges providers to function in ways that often contrast sharply with how they were trained to work. In addition to training staff to function in new ways, shaped by a population-based approach, the transformation of care must be supported by infrastructure to be sustained. Dozens of staff have attended recent national trainings in PC-MHI, and many have been clamoring for systematic guidance for how-to develop a viable integration system. While this relatively new care structure is evolving rapidly and often uniquely across the national system, the collective wisdom of the pioneers in this transformation has been gathered together here. Hopefully, the manual will highlight helpful structures and best practices for success, alert staff to common pitfalls, and save many the time otherwise spend to re-invent the wheel. As defined and required by the Uniform Mental Health Services Handbook (VHA Handbook ), there are two main categories of PC-MHI services; CCC and Care Management (CM). VA medical centers and large CBOCs must have on-site integrated care clinics utilizing a blended model that includes co-located collaborative care and care management, using the Behavioral Health Laboratory system, TIDES, or other evidence-based models. Co-located, Collaborative Care services offered by an embedded behavioral health provider: This approach involves providing services to primary care patients in a collaborative framework within primary care teams. Behavioral health visits are brief (generally minutes), limited in number (1-6 visits with an average of between 2 and 3), and are provided in the primary care practice area, structured so that the patient views meeting with the behavioral health provider as a routine primary care service and medical providers are supported across a broad scope of behavioral health concerns. Care Management (often provided via telephone): This approach includes mechanisms for systematic monitoring of symptoms and treatment emergent problems such as nonadherence or side effects; decision support; patient education and activation; and assistance in referral to specialty mental health care programs, when needed. CM services follow structured protocols designed around specific diagnostic entities such as depression and are generally implemented by behavioral health nurses or clinical social workers. The differences between PC-MHI programs and traditional mental health are dramatic, and generally require a culture shift for all stakeholders, from PCPs to BHPs and leadership. The following chart summarizes some of the differences. PC-MHI Co-located Collaborative Care Operations Manual June

6 Co-Located Collaborative MH Care Mental Health Specialty Care Location On site, embedded in the primary care clinic A different floor, a different building Population Most are healthy, mild to moderate symptoms, behaviorally influenced problems. Most have mental health diagnoses, including serious mental illness Provider Communication Collaborative & on-going consultations via PCP s method of choice (phone, note, conversation). Focus within PACT. Consult requests, CPRS notes, Focus within mental health treatment team. Service Delivery Structure Brief (20-40 min.) visits, limited number of encounters(avg. 2-3), same-day as PC visit. Comprehensive evaluation and treatment, 1 hour visits, scheduled in advance. Approach Problem-focused, solution oriented, functional assessment. Focused on PCP question/concern and enhancing PCP care plan. Population health model. Diagnostic assessment, psychotherapy and psychopharmacological, individual or group, recoveryoriented care. Broad scope that varies by diagnosis. Major Recommendations: The areas of training, personnel management, program monitoring and workload comprise the infrastructure for sustainability. This manual attempts to summarize what is recommended within each area, and to provide examples of successful and productive tools in each. 1. National PC-MHI Support: Trainings are offered through the National PC-MHI Program Office directed by Dr. Edward Post and the leaders of the care management programs (TIDES and BHL) as well as the Center for Integrated Healthcare. The PC-MHI website can be found at: and CIH SharePoint at It is recommended that staff working in integrated roles attend the corresponding training for that role. In addition, higher levels of facility management need basic familiarity with these concepts in order to ensure effective decision-making that does not conflict with integrated care. Integration must occur at all levels within the system, such that mental health managers/supervisors and team leaders routinely consult with medical counterparts related to integration progress and barriers. 2. Personnel Management: Recruiting, hiring, and supervising co-located, collaborative care behavioral health providers (CCC BHPs) for PC-MHI programs is a complex process that is critical to sustainability. Guidance is delineated in the body of this manual. Administrators must have a clear understanding of the nature and expectations for successful functioning in PC-MHI programs as a CCC BHP. It is recommended that direct supervisors of these roles PC-MHI Co-located Collaborative Care Operations Manual June

7 attend the related trainings and/or read the full Operations Manual and consult with national experts as needed. 3. Program Monitoring: This process should be an on-going dialogue between the provider and local level supervisors rather than limited to formal annual or semi-annual evaluations. The following tools should be utilized: 1. BHC Core Competencies Tool (Robinson & Reiter, 2007; See Appendix D): This rating scale describes six content domains and the specific skills required to master the competency. Providers should rate themselves and compare ratings with the review of the supervisor or trainer. 2. Chart reviews: A random sample of charts should be reviewed to check for competency within administrative and documentation skills. Domains such as relevance, conciseness, brevity and evidence of consultation should be documented. This kind of monitoring is critical to ensure initial competency, and helpful to repeat periodically as a form of ongoing quality assurance. 3. Observations: If possible direct clinic observation should occur. The trainer or program leader for PC-MHI can assist with this process by making site visits and observing direct interactions with patients as well as other clinical staff. Fidelity project is currently underway that will include the development of coding sheets to assist with this task. 4. Input from other primary care team members: In order to gauge team skills and integration with other PC members, the supervisor should consult with other PC team members and ask specific questions about program integration episodically. PACT team input should routinely be included in performance appraisals of PC-MHI mental health staff. 5. Dashboards: It is important to monitor trends in patients being seen by individual providers working within PC-MHI programs including the number of unique patients seen, the total number of encounters, the number of encounters per unique, the number of encounters per day, average session length, and the most common diagnoses seen in clinic. Most of these items are available through the national dashboard except the last two, which can be very good indicators of CCC implementation success. It is recommended that this function be delegated explicitly and time allotted to perform it, with routinely scheduled reports expected. 4. Workload Capture: The workload of BHPs (both CCC and CM) in a primary care setting is captured by using Clinic Stop Code 534, and 539 for group encounters. Detailed guidance on stop codes and CPT codes are available in Chapter 4 of the Operations Manual. Administrative Officers, supervisors, team leaders and front line PC-MHI staff need to be familiar with proper coding for this service. PC-MHI Co-located Collaborative Care Operations Manual June

8 Chapter One: Purpose, Background and Conceptual Framework Purpose of this Manual: This manual is provided to the field as operational support in service of successful and sustainable co-located, collaborative care (CCC) Primary Care-Mental Health Integration (PC-MHI). As defined and required by the Uniform Mental Health Services Handbook (VHA Handbook ), there are two components of PC-MHI services; CCC and Care Management (CM). This manual provides a detailed description of co-located, collaborative care behavioral health services integrated within primary care and some tools to support its implementation. Care management has been well described in other documents (e.g., Zanjani et al., 2008, Zeiss & Karlin, 2008) therefore we have not attempted to include more than a brief clarification here. This manual is designed for administrators such as careline managers, supervisors, integrated behavioral health providers, primary care providers, and others who have responsibility for managing the implementation and operations of PC-MHI programs. The primary aim of this manual is to provide a reference summarizing key infrastructure considerations, clarifying roles and responsibilities, and highlighting core competencies for PC-MHI work. Samples of logistical tools such as service agreements, policy memos, personnel guidance, CPRS progress note templates and general program management strategies are also provided. Note that there is a companion Education Manual that delineates in greater detail the nuts and bolts of these concepts, with sample templates that are designed as a primer in PC-MHI work for the new co-located, collaborative care (CCC) behavioral health provider (BHP). This manual is intended as guidance only. There has been and will continue to be considerable site-to-site variability in discipline-specific staffing levels, scopes of practice, skill sets, and access to specialty resources within primary care settings. Thus, any operational strategy must build in a degree of flexibility and fluidity to enable the behavioral and primary care partners to reach their own balance and share tasks commensurate with their particular circumstances. The need for local variability limits the degree of specificity within this manual, but also underscores the key principle that the charge of successful, real-time delivery of first level behavioral health care is really directed to the team and not the individual provider. The purpose of this manual is to delineate the systems and helpful structures to support CCC functioning. While blending is discussed, and staff need to be familiar with both roles, this manual provides implementation guidance for the CCC role, just as the BHL manuals provide it for the BHL model of care management. Primary Care Mental Health Integration Requirements: The concept of PC-MHI is derived from the Institute of Medicine s description: Primary Care is the provision of continuous, comprehensive, and coordinated care to populations undifferentiated by gender, disease, or organ system. Primary care is the provision of accessible, integrated, biopsychosocial health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community (emphasis added- IOM, 1996). All 153 VA hospitals are required to provide access to mental health care in the context of primary care clinics as directed in the VHA Handbook of September 2008 titled Uniform Mental Health Services in VA Medical Centers and Clinics. This handbook outlines the essential elements of mental health programming, including integration within primary care clinics. The handbook states PC-MHI Co-located Collaborative Care Operations Manual June

9 that all medical centers and large CBOCs serving more than 5,000 patients must provide a blend of co-located, collaborative care and evidence-based care management services, such as those offered through the Behavioral Health Lab or TIDES models (VHA Handbook , p. 35). This manual focuses on the co-located, collaborative care services, and addresses the concept of blending with care management services. Co-located Collaborative Care: The Uniform Mental Health Services handbook states the colocated, collaborative care (CCC) model involves one or more mental health professionals who are integral components of the primary care team and who can provide assessment and psychosocial treatment for a variety of mental health problems, which include depression and problem drinking (VHA Handbook , p. 35). Zeiss and Karlin (2008) note that the embedded provider is often a psychologist but could be a different mental health professional, and that these professionals provide immediate follow-up of positive screens for mental health problems. In addition to follow-up assessments for positive screens, the co-located mental health provider also can assess any Veterans who are identified by the PCP as likely to benefit from mental health services. Zeiss and Karlin go on to note that the provider also offers consultation to PCPs on strategies for managing challenging behaviors as well as to provide behavioral medicine services for broader health issues. The CCC model is said to emphasize immediate face-to-face connection with patients identified with mental health needs in a primary care visit and the use of evidence-based psychotherapy and health behavior management (Zeiss & Karlin, 2008). The second component of integrated care delivery within the VA is care management, which, according to the Handbook includes mechanisms for systematic monitoring of symptoms and treatment emergent problems such as non-adherence or side effects; decision support; patient education and activation; and assistance in referral to specialty mental health care programs, when needed. The care management component can be based on the Behavioral Health Laboratory, the Translating Initiatives for Depression into Effective Solutions (TIDES) model, or other evidencebased strategies approved by the Office of Mental Health Services. These two categories of care are required offerings by all medical centers and large CBOCs, as is the blending of the two. Varied models of blending have evolved, including those that structure the CCC staff as gatekeepers of referrals and those that utilize health technicians and care managers to provide comprehensive follow-up to initial positive screens and refer patients with positive results directly to care management for further assessment and/or treatment. In addition to the need for thoughtful and purposeful blending of CCC and CM functions, the addition of Health Behavior Coordinators (HBC) throughout the system provides another opportunity for collaboration and challenge for coordination. While the HBC staff have limited clinical time allotment, they are central to training Patient Aligned Care Team (PACT) staff in behavior change techniques, and can complement the other PC-MHI staff in this process. It is recommended that staff in these three roles meet episodically (at least monthly initially and quarterly after roles are well-established) to ensure effective collaboration, clarify who will do what, and keep each other informed of various initiatives. Co-Located, Collaborative Care Mission Statement: Consistent with the service philosophy of primary care, the mission of the CCC component of integrated primary care is to detect and address the broad spectrum of behavioral health needs among primary care patients, with the aims of early identification, quick resolution of identified problems, long-term problem prevention, and healthy lifestyle support. PC-MHI Co-located Collaborative Care Operations Manual June

10 A major goal of this model is to support the primary care provider in identifying and treating patients with mental health diagnoses and/or need for behavioral interventions. This approach involves providing services to primary care patients in a collaborative framework with primary care team providers and staff. The focus is on resolving problems within the primary care service context. In this sense, the behavioral health provider is a key member of the primary care team. Behavioral health visits are brief (generally minutes), limited in number (1-6 visits with an average of between 2 and 3 per VSSC dashboard), and are provided in the primary care practice area, structured so that the patient views meeting with the behavioral health provider as a routine primary care service. The referring primary care provider is the chief customer of the service and, at all times, remains the overall care leader. This model of co-located, collaborative care with embedded behavioral health providers in primary care clinics represents a main entry point in the continuum of care which should include a range of effective delivery methods that are convenient to Veterans and their families (VA Strategic Plan, 2010, p. 33). Conceptual Framework: In the Department of Veterans Affairs Strategic Plan for , Secretary Eric Shinseki writes Our mission at VA is to serve Veterans by increasing their access to our benefits and services, to provide them the highest quality of health care available, and to control costs to the best of our abilities. Delivering mental health services embedded in the context of primary care clinics allows for highly accessible, evidence-based and cost-effective care. Added benefits include reduced stigma for services and a stepped care structure that facilitates smooth linkage with specialty services as needed. Further, a majority of the Mental Health Performance Measures outlined in the DVA Strategic Plan identify new cases of alcohol misuse, depression and PTSD, that can be addressed at least initially by staff working in PC-MHI clinics. In response to such a dynamic mission and far-reaching set of expectations, primary care delivery within VHA both locally and nationally is evolving into an increasingly sophisticated interdisciplinary team based, patient-centered medical home approach known as the Patient Alliance Care Team (PACT). This model represents the next evolution of health care delivery that has been embraced by the VA. It aims to replace episodic illness and complaint- based care with coordinated, proactive, preventive care and a long term healing relationship with the healthcare team. The primary care team focuses on the whole person, including psychosocial aspects of functioning. One of the core features of patient centered team work is shifting healthcare services away from the acute care model and toward a more patient-centered model that focuses on wellness and disease prevention (VA Strategic Plan, 2010). Well-designed and implemented Primary Care-Mental Health Integration (PC-MHI) supports this goal in part by addressing mental health concerns at the sub-clinical, minor or moderate levels before they escalate to full diagnostic level problems. It is the expectation that PC-MHI providers interact and blend services with other PACT members, as part of the extended team, providing services across multiple teamlets, typically consisting of a primary care provider, a RN, a LPN, and a PSA that function together as a team to meet the needs of a specified panel of patients. The emphasis in this model of integration is on life functioning, with the goal of early remediation of symptoms. For those patients who present with more serious psychosocial difficulties, effective integration allows for rapid, on-site assessment as needed and increased rates of successful linkage to specialty care. Specifically, there is evidence that patients in need of specialty services who receive motivational intervention are far more likely to keep their scheduled appointments than those who do not receive this intervention (Zanjani, Miller, Turiano, Ross, & Oslin, 2008). In addition to providing person-centered, accessible care in the medical clinic context as part of the PC-MHI Co-located Collaborative Care Operations Manual June

11 medical team for minor to moderate concerns, there is a subset of patients who meet mental health diagnostic criteria for more serious concerns but are unwilling to consider care in a specialty clinic setting, for whom integrated behavioral health services may be the only acceptable avenue of service. In general, the approach of CCC providers is a stepped care, population-based model that strives to care for the health needs of the population by providing brief, structured, evidence-based care on a wide range of presenting concerns and facilitating linkage with more intensive specialty treatments as needed. Several sites tracking referral patterns related to integration services have demonstrated a reduction in referrals to specialty care as well as transformation of access from a system with long delays and waits to one of same-day service. This level of accessibility serves the needs of both good patient care and good medical provider support. In this model of embedded integration, the primary care provider (PCP) is a primary customer, and services from the behavioral health provider include consultation and close collaboration with the medical teams, including the PCPs, in the service of coordinated and comprehensive healthcare. Team members include staff from nursing, behavioral health, pharmacy, nutrition, health behavior coordinators, medical social workers and clerical staff. One well-known example of a site that has successfully implemented an open-access, co-located collaborative model of service delivery is the White River Junction VA. Led by Dr. Andrew Pomerantz, this site utilizes a uniquely efficient system of gathering screening responses via laptop computer prior to actually meeting with the patient to maximize the efficient use of time during the appointment (Pomerantz, 2007). Contrast with Specialty Mental Health: There are several defining characteristics of CCC service delivery (e.g., brief, targeted assessment, consultation, intervention and triage) that differ substantially from the delivery of specialty mental health care service delivery as outlined in Table 1. It is critical for administrators, supervisors and clinicians to gain conceptual mastery of these features in order to make decisions in support of effective functioning for both specialty and integrated care services. When well understood, flow issues are more readily resolved, and resources appropriately allocated, and patients are most likely to be cared for in the appropriate setting. For the bulk of experienced mental health staff working in primary care clinics today, there was no academic training in this relatively new integrated approach. Few clinicians enter these roles with the practice management skills and core competencies to function optimally within the PACT service delivery structure. Simply assigning a traditionally trained clinician to work in the PC-MHI setting presents a challenge for successful implementation as often do not have the skills to succeed. Training through formal conferences, reading recommended texts, shadowing experienced PC-MHI staff, and consulting with clinical leaders in the system can be instrumental in developing the skills for success in PACT work. The practice differences are substantial and generally require a culture shift for all stakeholders, from PCPs to BHPs as well as local leadership. Specifically, it is important that CCC providers have offices within the PC clinic whenever possible. This allows for frequent team consultations, warm hand-offs, informal interactions, and decreased stigma for patients. Services provided in CCC should meet the needs of the population and be brief in nature (e.g., minutes). If CCC providers do not understand this alternative practice management style and schedule patients for minutes of repeated psychotherapy sessions, they quickly become inaccessible for warm hand-offs. The population served by CCC providers is typically high functioning with mild to moderate symptoms. Those with severe symptoms are generally not appropriate for continued mental health care with the primary care environment. However, treating PC-MHI Co-located Collaborative Care Operations Manual June

12 those with mild to moderate symptoms in primary care increases the access to specialty mental health services for those who need more intensive levels of care. The following chart summarizes some of the differences between CCC services and mental health specialty care. Co-Located Collaborative MH Care Mental Health Specialty Care Location On site, embedded in the primary care clinic A different floor, a different building Population Most are healthy, mild to moderate symptoms, behaviorally influenced problems. Most have mental health diagnoses, including serious mental illness Provider Communication Collaborative & on-going consultations via PCP s method of choice (phone, note, conversation). Focus within PACT. Consult requests, CPRS notes, Focus within mental health treatment team. Service Delivery Structure Brief (20-40 min.)visits, limited number of encounters(avg. 2-3), same-day as PC visit. Comprehensive evaluation and treatment, 1 hour visits, scheduled in advance. Approach Problem-focused, solution oriented, functional assessment. Focused on PCP question/concern and enhancing PCP care plan. Population health model. Diagnostic assessment, psychotherapy and psychopharmacotherapy, individual and group, recoveryoriented care. Broad scope that varies by diagnosis. Integration Support Systems: The VA has structured national support for integration efforts through The National Primary Care- Mental Health Integration (PC-MHI) Program Office, directed by Dr. Edward Post, the VISN 2 Center for Integrated Healthcare, Philadelphia Behavioral Health Lab (VISN 4 MIRECC), TIDES Care Management, and Mental Health QUERI. The PC-MHI office opened in 2008 and provides leadership to integration efforts in a variety of ways. They coordinate regular national trainings on PC-MHI, produce a quarterly newsletter, provide monthly educational conference calls, and provide evaluation of integration efforts. In conjunction with staff from the VSSC, they have developed a data cube to track related workload and diagnostic use in addition to data gathering from the annual staff survey. Trainings are offered several times a year that bring together top leaders in the field to teach staff from around the country the concepts and skills of successful care management, as well as leadership training for PC-MHI program management. Their website can be found at: PC-MHI Co-located Collaborative Care Operations Manual June

13 The Center for Integrated Healthcare (CIH) is a VA Office of Mental Health Services funded Mental Health Center of Excellence which opened in November 2004 with a mission of improving the health of Veterans by integrating mental health services into the primary care setting, thus increasing both access and quality of care for Veterans. Further, consistent with the Department of Veterans Affairs FY Mental Health Initiative Operating Plan: Improving Veterans Mental Health, CIH supports the continued implementation of the Uniform Mental Health Services Handbook (VHA Handbook ) transformational initiatives, by conducting research, providing education and training to develop highly skilled CCC providers, and by serving as a clinical resource to the entire VA healthcare system for successful program implementation. CIH trainings in co-located, collaborative care are offered several times a year and bring together top leaders in the field to teach staff from around the country the concepts and skills of successful onsite integration. Given the lack of academic preparation for these relatively new roles, sending staff to either CIH training in CCC or PC-MHI training for care management and PC-MHI Program Leadership may be very helpful in shifting the care delivery culture from traditional care to integrated care. PC-MHI Co-located Collaborative Care Operations Manual June

14 Chapter Two: Roles and Responsibilities of Behavioral Health Providers within Primary Care-Mental Health Integration Introduction The literature states that up to 70% of primary care patient appointments include psychosocial concerns covering both the full spectrum of psychiatric disorders (from subclinical distress to serious mental health concerns) and a range of behavioral concerns from insomnia, adherence, and pain management to lifestyle issues such as weight management and tobacco dependence. The majority of psychotropic medications are written by PCPs, and the system s demands on the primary care providers have grown exponentially, limiting their ability to manage the volume of behavioral health issues they face. Most have neither the time nor the training to provide effective behavior management techniques. Thus, the Behavioral Health Provider s (BHP) role is critical to comprehensive healthcare. They are tasked with providing brief assessments, targeted treatment, triage, and management of primary care patients with medical and/or behavioral health problems. Consequently, integrated primary care interventions focus on helping patients replace maladaptive behaviors with adaptive ones, provide skill training through psycho-education and patient education strategies, and focus on developing specific behavior change plans that fit the fast work pace of the primary care setting. These interventions are developed in collaboration with the patient and other PC providers and implemented within the primary care context. Types of PC-MHI Behavioral Health Providers: Co-Located, Collaborative (CCC) Behavioral Health Providers: The CCC Behavioral Health Provider (BHP) is typically a social worker, a psychiatric nurse or a psychologist. The BHP s role is to provide support and assistance to both PCPs and their patients without engaging in any form of extended specialty behavioral health care. These disciplines will cover BHP responsibilities of triage and consultation at PCP request. Care Managers (CM): CM protocols are designed around specific diagnostic entities such as depression and anxiety and are generally implemented by behavioral health nurses or clinical social workers. Service delivery can be done via telephone in the CM model, so embedded location is not central to this role. Prescribing Behavioral Health Providers: In addition to behavioral interventions, all primary care settings should have access to a prescribing behavioral health provider. These providers include psychiatrists or psychiatric nurse practitioners with psychotropic prescription privileges, available onsite or via telepsychiatry. Definition of Roles: PC-MHI Co-located Collaborative Care Operations Manual June

15 Co-located, Collaborative Care (CCC) Providers The CCC provider refers to those mental health staff who are embedded in the Patient Aligned Care Teams (PACT) and focus on general service delivery for a wide range of concerns. While it is likely that the majority of presenting concerns addressed involve traditional mental health problems such as depression, anxiety, PTSD and substance misuse, the intended scope of these roles encompasses all behavioral issues that impact health, such as pain management, insomnia, tobacco dependence, weight management etc. A distinguishing feature of the general IPC approach is that it casts a wide net in terms of who is eligible. From a population based care perspective, the goal is to offer and provide brief, general behavioral health services to as many patients in need of care as possible. Traditional primary care medicine is largely based upon this approach. The idea is to tend the flock by providing a large volume of general health care services, none of which are highly specialized. Patients who truly require specialized expertise are usually referred into medical specialties, such as specialty mental health care. An additional distinguishing feature of the CCC role is to intervene with patient problems even when they are sub-syndromal, in hopes of averting progression to full diagnostic symptomatology. To this end, patient functioning is emphasized more than diagnostic criteria. For example, a brief intervention for alcohol misuse is likely to be appropriate for many patients whose drinking levels exceed healthy limits, and may prevent a progression to dependence, but may not meet criteria for abuse or dependence. Behavioral Health Providers working in this role are generalists with a wide range of skills and a willingness to work within available evidence-based protocols in support of their medical colleagues in busy clinic settings. At all times, care is coordinated by the PCP, who is still responsible for monitoring the results of interventions. Communicating back to PCPs on a daily basis is one of a BHP s highest priorities, even if it means handwritten notes, , or staying late to have a faceto-face conversation. BHPs will communicate with PC providers in both written and verbal form (i.e, face-to-face or over the telephone). Care Managers Care management services provide a consistent, protocol-based and empirically supported treatment package approach, and are available for particular diagnostic groups. Primary care patients in need of these services will include those with high prevalence, high impact (in terms of resource use) conditions such as uncomplicated depression, anxiety, PTSD, alcohol misuse, and chronic pain. According to the UMHS Handbook, CM includes mechanisms for systematic monitoring of symptoms and treatment emergent problems such as non-adherence or side effects; decision support; patient education and activation; and assistance in referral to specialty mental health care programs, when needed. These interventions have historically been organized under two specific evidence-based models in the VA: TIDES and Behavioral Health Lab (BHL). These two models are in the process of merging at the time of this writing. The CM protocols are designed around specific diagnostic entities such as depression and anxiety and are generally implemented by behavioral health nurses or clinical social workers. Service delivery can be done via telephone in the CM model, so embedded location is not always central to this role. Prescribing Behavioral Health Providers: The primary responsibility of the prescribing behavioral health provider is to enhance the PCP s psychoactive medication management by providing verbal consultation on the PCP s initial medication decisions, medication changes, and the management of routine side effects. For more chronic, complicated, and/or refractory patients, the prescribing behavioral health provider may assess the patient directly to develop a medication regimen. In these instances, the PCP would take over renewal of prescriptions, once the patient is stabilized. If the patient does not stabilize, referral to behavioral health specialty care will be facilitated by BHPs. These functions are more fully described below and outlined in the sample Service Agreement attached in Appendix A: PC-MHI Co-located Collaborative Care Operations Manual June

16 Initiation of pharmacotherapy: As PCPs develop assessment skills, routine initiation of anti-depressant treatment may not require consultation. Consultation may be indicated if prior psychiatric treatment history is unusually complex, there is suspicion of more complex psychiatric diagnosis (e.g., bipolar disorder, psychotic disorder, personality disorder), concern about lethality, or the choice of psychotropic treatment is complicated by co-morbid medical illness/other medications. For those sites with pharmacy support the clinical pharmacist in the primary care setting may be integrated into this process. Failure to respond to initial pharmacotherapy: This category accounts for the bulk of consultations to the prescribing behavioral health provider among patients with anxiety and mood disorders. Failure to respond to initial treatment may result from imprecise diagnosis, inadequate medication dosage, medication intolerance (e.g., side effects), co-morbid medical illness, substance abuse/dependence, poor treatment adherence, or refractory illness. Relapse on pharmacotherapy: Symptom relapse while receiving active psychotropic treatment often prompts a request for psychiatric consultation. In some cases, augmenting or switching medications may be necessary. Transfer of responsibility back to the primary care PCP (after stabilization) is often appropriate. Defining Characteristics of Co-located, Collaborative Care The delivery of CCC behavioral health services is, by necessity, very different than the delivery of behavioral health services in the traditional, specialty behavioral health clinic. Table 2 provides an overview of CCC service delivery characteristics structured by domains of core competencies (Robinson & Reiter, 2007). Table 2: Defining Attributes and Core Competencies of CCC Domain Attribute I. Clinical Practice Skills 1. Applies principles of population based care for everyone along a continuum from acute need, sub clinical problems & prevention, to those who are healthy. 2. Defines CCC Role with patient before starting assessment (able to say intro accurately; e.g., deliver memorize script content in 2-minutes or less). 3. Rapid problem identification (able to determine if referral problem is what the patient sees as the problem in the first minute after the intro script is finished for 90% of all first consultation appointments). 4. Uses appropriate assessment questions (e.g., ask questions geared towards current problem referral and functioning & how the patient s physical condition, thoughts, emotions, behaviors, habits, and environment are impacting/influencing the identified problem and functioning). 5. Limits problem definition/assessment (focuses on presenting problem). Does not assess other areas (except suicide and homicide as indicated for depressed and stressed individuals) until assessment of initial referral problem is complete and as time allows. PC-MHI Co-located Collaborative Care Operations Manual June

17 6. Focuses recommendations and interventions on functional outcomes and symptom reduction (e.g., improve ability to work, improve performance on responsibilities at home, increase frequency or improve quality of social interactions [friends], increase intimate/familial interactions [spouse, children], increase exercise, enjoyable or spiritual activities, improved sleep, decreased autonomic arousal, decreased pain exacerbation, improved mood). 7. Teaches self-management skills/home-based practice as the prime method for decreased patient symptoms and improved functioning (e.g., deep breathing, cue controlled relaxation, cognitive disputation, sleep hygiene, stimulus control, eating behavior changes, increased physical activity, problem solving, and assertive communication). The majority of what the patient does to decrease symptoms and improve functioning is done outside of the consultation appointment. 8. Interventions are specifically (operationally) defined and supportable by primary care team members (e.g., increase fun activities [read Mon, Wed, Fri from in home office], increase exercise [Mon-Fri from , 30-minutes on stair-stepper], use relaxation skills). 9. Shows understanding of relationship of medical and psychological systems (e.g., biopsychosocial model of physiological disorders, can describe to the patient the relevant factors, physical, behaviors, thoughts, environment, interactions with others, impacting symptoms and functional impairments). 10. Shows basic knowledge of medicines (can name basic anxiety and antidepressant meds and what might be a first line recommendation for specific symptom presentation). II. Practice Management Skills 1. Uses 30-minute appointment efficiently (e.g., identify problem, how functionally pt is impaired, symptoms, summarize to patient understanding of problem during at the 15 minute point, use next 10 minutes to develop and start a behavioral change plan). 2. Stays on time when conducting consecutive appointments. 3. Demonstrates capacity to consistently use intermittent visit strategy (e.g., see patient in 2 wks or in 1 month instead of every week), telephone visits, and secure messaging as available. 4. Appropriately suggests the patient seek specialty behavioral health care when the intensity of service needed to adequately address the patient s problem is beyond what can be done in consultation appointments (e.g., PTSD, OCD, Marital Counseling, ETOH abuse/dependence). PC-MHI Co-located Collaborative Care Operations Manual June

18 5. Uses community resources referral strategies (e.g., Military One Source, community retirement center for those using primary care for social contact, self-help divorce group, etc.). III. Consultation Skills 1. Focuses on and responds to referral question (e.g., specifically talks about evaluation regarding initial referral question). 2. Tailors recommendations to work pace of primary care (e.g., recommendations given to PCPs be done in 1-2 minutes by the PCM when/if they see the patient again). 3. Conducts effective feedback consultations (e.g., when giving feedback keep to 1 minute or less and use specific straight-forward short explanations). 4. Willing to aggressively follow up with providers, when indicated (e.g., medication recommendations for depression/anxiety, significant side effects for meds, alarming medical symptoms). 5. Focuses on recommendations that reduce providers visits and workload (e.g., recommend patient see you in two weeks to assess symptoms and functional changes and response to medications instead of seeing PCM). IV. Documentation Skills 1. Writes clear, concise medical record notes (e.g., focus on referral problem, frequency, duration, acute or long-term, functional impairment, short specific recommendations). 2. Notes are consistent with feedback to the PCM (e.g., note is a general outline of the verbal information or you give/send the PCM). In general, the integrated primary care model does not involve providing any type of extended behavioral health care to the patient. Some interventions are single session visits, with feedback about psychological intervention strategies made immediately available to the referring provider. Interventions with patients are simple, bite-sized and compatible with the types of interventions that can be provided in a minute health care visit. It is also clear to the patient that the BHP is being used to help the PCP and patient come up with an effective plan of attack to target the patient s concerns. Follow-up consultations are choreographed to reinforce PCP generated interventions. The goal over time is to maximize what often amounts to a very limited number of visits to either the BHP or the PCP. Thus, the BHP is able to follow patients who need longer term surveillance at arm s length, in a manner which is very consistent with how PCPs manage their at risk patients. The underlying philosophy is one of taking a Veteran-centric approach to enable long-term independent success in problem-solving. This style involves a focused, solution oriented approach to problem-solving that incorporates evidence-based interventions whenever possible. While practicing within PC-MHI programs and utilizing a CCC service delivery framework, the PCP ultimately remains in control over the plan of care for the patient. Thus, the CCC provider is functioning under the jurisdiction of the PCPs treatment plan for the patient. A separate behavioral health treatment plan is not needed because the CCC provider is considered an extension of primary care services. PC-MHI Co-located Collaborative Care Operations Manual June

19 A final notable aspect of the integrated primary care model is that it allows in vivo training to occur, built around specific casework. Over time, with feedback regarding hundreds of patients sent to the consultant, PCPs begin to see the same themes recur in their panel of patients and also gain firsthand experience using effective strategies, supported by the BHP. Eventually, the PCP and the BHP learn to integrate the skills over time and implement both psychological and medical interventions more effectively. Services Included in Co-located, Collaborative Care There are several different types of services that occur within CCC. These are described below: CCC Initial Consult Visit: Initial visit with a patient referred for a general evaluation or determination of level of care; focus on functional evaluation, recommendations for treatment and forming limited behavior change goals; involves assessing patients at risk because of some life stress event; may include identifying if a patient could benefit from existing specialty care or community resources; consultation with clinical pharmacist, or referral to medical social worker. (CPT code or 96150, infrequently coding is needed/appropriate. See chapter 4 for more details.) CCC Follow-Up Visit: Visits by a patient to support a behavior change plan or treatment target identified by the PCP on the basis of earlier consultation; often in tandem with planned PCP visits. (CPT code or 96152) Treatment Adherence Enhancement Visit: Visit designed to help patient adhere with intervention initiated by PCP; focus on education, motivational interviewing, addressing negative beliefs, or strategies for coping with side effects. (CPT code or 96152) Relapse Prevention Visit: Visit designed to maintain stable functioning in a patient who has responded to previous treatment; often spaced at long intervals. (CPT code or 96151) Behavioral Medicine Visit: Visit designed to assist patient in managing a chronic medical condition or to tolerate invasive or uncomfortable medical procedure; focus may be on lifestyle issues or health risk factors among patients at risk (e.g., headache management, tobacco cessation, weight loss); may involve managing issues related to progressive illness such end-stage COPD, etc. (CPT code 96152) Psycho-educational Group Visit: Brief group interventions that either replace or supplement individual consultative treatment, designed to promote education and skill building/effective problem-solving. Often a psycho-educational group can and should serve as the primary psychological intervention as many behavioral health needs are best addressed in this type of group treatment. (CPT code or 96153) Conjoint Consultation: Visit with PCP and patient designed to address an issue of concern to both. (CPT code or 96152) Telephone Consultation: Intervention contacts or follow-ups with patients that are conducted by the BHP via telephone, rather than in-person. (CPT codes for Nonphysicians: (5-10 min), (11-20 min), (21-30 min) and Physicians: (5-10 min), (11-20 min), (21-30 min) Walk-In Behavioral Health Consultation: Usually unscheduled staff- or patient-initiated contact with the BHP for an immediate problem-focused intervention (CPT code or PC-MHI Co-located Collaborative Care Operations Manual June